Post-LASIK ectasia: a hazy crystal ballThere is no doubt that more direct corneal biomechanical measurements are needed to avoid post-LASIK ectasia, but until we have those, what preoperative variables should we focus on?

At Refractive Surgery Subspecialty Day, speakers addressed the risk factors for and management of post-LASIK corneal ectasia in a session titled “Battle of the Bulge.” While all agreed that the incidence of post-LASIK ectasia is decreasing and that corneal crosslinking may ultimately be the best treatment for it, there was some debate over how well certain preoperative factors can predict it.

According to J. Bradley Randleman, MD, age and topography are clearly useful indicators. “Age not only has been scientifically validated on more than one occasion but it also makes sense that, as one ages, the topographical changes become more evident,” he said.

Dr. Randleman defended his five-point Ectasia Risk Factor Score System against a study published in Clinical & Experimental Ophthalmology last year that concluded his scale can miss a significant portion of patients at risk of ectasia. According to Dr. Randleman, the authors misclassified some patients as low risk due to insufficient analysis of corneal topography.

“It’s the first time I’ve begun to agree with some of the things Brad said,” remarked Perry S. Binder, MD, as he took the podium after Dr. Randleman. Dr. Binder agreed that more accurate corneal biomechanical measurement tools are needed and that the incidence of post-LASIK corneal ectasia has decreased. However, he said, we have a long way to go to get to 100 percent accuracy. “The avoidance of all risk factors does not guarantee that ectasia will not occur.” —Mark Simborg

Dr. Binder is a consultant to Abbot Medical Optics and AcuFocus and reports a patents/royalty interest in Outcomes Analysis Software. Dr. Randleman reports no financial interests.

He recently conducted a retrospective review to compare visual outcomes in two groups of eyes with macular pucker. In all eyes, small-incision vitrectomy (23-gauge) was used with air tamponade. In one group of 40 eyes, epiretinal membrane (ERM) peeling was performed using only triamcinolone suspension to visualize the ERM; and in the other group of 40 eyes, triamcinolone was first applied followed by an application of brilliant blue to stain and remove residual ILM (i.e., double peeling).

While double peeling did a better job of removing ERM, there was no difference in visual acuity between the groups.

But what about late retinal changes after ILM peeling? About 14 percent of eyes had arcuate swelling of the retinal nerve fiber layer, even though visual acuity remained unchanged.

Dr. Chang said the results of this study and lingering questions about late retinal changes after ILM peeling have caused him to change his technique for macular hole surgery. Instead of extensive ILM peeling, he now just peels a small zone of ILM around the hole.

Dr. Chang believes that future long-term studies are warranted to determine the need for and the extent of ILM peeling that is necessary.—Susanne Medeiros
Dr. Chang is a consultant for Alcon and Alimera Sciences, and also has a patents/royalty interest in Alcon.

Povidone-iodine may become the gold standard for intravitreal injection endophthalmitis prophylaxisIntravitreal injections have become one of the most common medical procedures in the United States, with 1.2 million injections performed under Medicare alone in 2009, but there is no current gold standard for endophthalmitis prophylaxis, said Charles Wykoff, MD, PhD, during Retina Subspecialty Day.

However, there is evidence that the community standard is evolving toward antisepsis and away from prophylactic use of topical antibiotics. He said recent data suggest that topical antibiotics either before or after intravitreal injection are unnecessary. Worse yet, they may be counterproductive by contributing to significant bacterial resistance. They also impose a high cost on our health care system.

Dr. Wykoff made a strong case for using only povidone-iodine to prevent endophthalmitis. It has the advantages of low cost, broad-spectrum activity, widespread availability, fast bactericidal rate and absence of resistance.

One disadvantage of povidone-iodine is purported allergy. “It seems to come up all the time,” he said, but it may not be a true allergic reaction. “In some cases, the patients are really experiencing irritation, which occurs in about 5 percent of cases. Just make sure you wash it out.”

Anaphylaxis to iodine does not exist, and there have been no reported cases of anaphylaxis to povidone-iodine related to ophthalmic use, he said. Many clinicians apply additional povidone-iodine to the conjunctiva immediately preceding insertion of the needle through the pars plana. If a small amount of povidone-iodine is inadvertently introduced into the vitreous cavity during the injection, it is unlikely to cause a problem. Animal models have shown ocular tolerance following intravitreal injection of significant volumes of povidone-iodine.

To those who are concerned with medicolegal issues, Dr. Wykoff noted that from 2006 to 2011, the Ophthalmic Mutual Insurance Company (OMIC) has received no claims or lawsuits related to nonuse of topical antibiotic prophylaxis with intravitreal injections. As a result, OMIC states that “decisions regarding use of antimicrobial and antiseptic prophylaxis should be based on best available science and not risk mitigation.”—Susanne Medeiros

27-gauge vitrectomy shows promise for challenging diabetic casesUsing a 27-gauge vitrectomy system for treating challenging diabetic retinopathy cases may result in similar anatomic success, fewer complications and favorable visual recovery compared with larger-gauge systems, according to preliminary study results presented during the Retina Subspecialty Day. Yusuke Oshima, MD, provided an update on developing technology for performing transconjunctival sutureless 27-gauge vitrectomy and discussed the results of a retrospective chart review on the use of this technique to treat tractional retinal detachment resulting from severe proliferative diabetic retinopathy.

He said that use of these smaller instruments for these difficult cases can make it easier to insert instruments into a tiny space and to perform membrane dissection, and it requires fewer instruments overall. The study included 40 patients (42 eyes) who were followed for a mean of 11.3 months. All procedures were conducted by 27-gauge vitrectomy with chandelier illumination and a wide-angle viewing system. Primary anatomic success was achieved in 93 percent of cases and final anatomic success in 100 percent.—Lori Roniger

Sutureless sulcus fixation for IOL rescueModification of sutureless sulcus fixation may provide vitreoretinal surgeons with an improved option for IOL rescue, according to a presentation during Retina Subspecialty Day by Jonathan Prenner, MD. “It takes advantage of the unique skills and toys of the vitreoretinal surgeon,” he said.

IOL rescue or implantation of a secondary IOL in eyes that have insufficient capsular support remains a unique challenge, he explained. Risks include suture rupture and corneal decompensation. The standard approaches are all reasonable, perhaps because each has advantages and disadvantages, he said.

Dr. Prenner and his colleagues have developed a technique for performing ciliary sulcus–based sclerotomy that he said is an efficient way of achieving a posterior lens position and excellent centration and stability, as well as avoiding reliance on sutures. Steps of the procedure include using a 20-gauge microvitreoretinal blade to create sclerotomies. The procedure also involves bending a 25-gauge disposable forceps in order to maximize the angle best suited for haptic externalization.

They have performed the procedure in 25 patients, of whom 12 have been followed for at least six months. All eyes experienced significant improvement in visual acuity, with no postoperative complications. The study is ongoing, and the research team expects to provide further results.—Lori Roniger

Dr. Prenner is a consultant to Alimera, Neovista and Ophthotech; an equity owner in Neovista and Ophthotech; and receives lecture fees from Ophthotech.

Editor’s note: Dr. Prenner’s presentation was a highlight of Dr. Drew Somerville’s brief video report on the Retina Subspecialty Day meeting, posted in the “Annual Meeting” group of the Academy’s Online Community.

From D.C.: New CMS rule raises viability of ACO option as Medicareconsiders alternatives to fee-for-serviceThe Centers for Medicare & Medicaid Services (CMS) yesterday released its final rule for Accountable Care Organizations (ACOs), incorporating changes sought by physicians and other Medicare providers to an earlier proposed rule.

The new rule will be discussed during the 2012 Medicare Update (Sunday, 12:15 to 1:45 p.m., in the Chapin Theater). In the meantime, here are some key points that you should know about.

Created in the health care reform law as a new way to organize health care in the marketplace, ACOs are one option that CMS will pilot in 2012 as the agency explores alternatives to the current fee-for-service Medicare reimbursement system. ACOs are designed to encourage primary care doctors, specialists, hospitals and other providers to coordinate their care for Medicare beneficiaries and to increase quality and efficiencies. In some specialties, such as ophthalmology, physicians will continue to be paid fee-for-service by Medicare and will likely contract with multiple ACOs.

With the changes to its final rule, CMS will:

Provide support to physician-owned practices and rural providers to build necessary staffing or IT infrastructure.

Implement a shared-savings arrangement with some advanced payment to the ACO.

Significantly reduce the number of mandatory quality measures an ACO must meet, with a more gradual phase-in of those measures.

Passages: Byron Demorest, MD (1925–2011)Byron H. Demorest, MD, who served as the Academy’s president in 1985, died on Friday, Oct. 14, of multiple myeloma, his family said.

“Byron was a giant in the gentlest, most humorous way,” said Susan H. Day, MD, a former Academy president (2005). “He lived what he preached; the last thing he expected was another ribbon or another accolade. He also was not afraid to speak the truth. I vividly recall his lecture on what was then called ‘dyslexia,’ when a popular late 1960s magazine pictured a child with red/green glasses watching TV, with the header announcing that a cure had been found. Dr. Demorest’s message was, ‘Don’t believe everything you read.’ He accurately pointed out that the same magazine cover, in smaller print, declared, ‘LBJ says we are winning in Viet Nam.’ We will all miss him. He served his patients, his profession and his community in an elegant yet home-grown style, with the utmost humility and humor.”

Among his many achievements, Dr. Demorest was instrumental in establishing the University of California, Davis, school of medicine in Sacramento and was founding chairman of its ophthalmology program. “Byron was in so many ways a visionary,” said Mark Mannis, MD, the current chairman of ophthalmology at UC Davis. “He realized that, in addition to a private-practice community, the state capital needed a strong academic program for training young ophthalmologists.”

Quote of the day“We’re doing lots of stuff to get away with not understanding what we’re doing,” said Dan Z. Reinstein, MD, during a discussion of how to identify keratoconic eyes and avoid sending them into ectasia-causing situations.

AGS Subspecialty Day Lecturer says surgical therapy deserves more respectIntroduced with a warning that singing might be involved, AGS Subspecialty Day Lecturer Dale K. Heuer, MD, took the podium and produced a wow factor.“

In cataract surgery, there’s all this stuff that gives it a wow factor,” Dr. Heuer said. “Glaucoma patients have similar expectations from their surgery, but it’s more like a whoa factor.” Meaning that both glaucoma physicians and patients are reluctant to opt for surgery.

“We’ve made a lot of progress, and there’s a lot of innovation occurring now,” Dr. Heuer said. But there are certain ways of thinking that are holding glaucoma surgery back. The main problem? A bias toward medical therapy and away from surgical therapy.

“A lot of it is tradition,” Dr. Heuer said. “We also have a justified fear of surgery. … Most of it goes well, but when it doesn’t go well, it’s like the gift that keeps on giving.”

However, Dr. Heuer pointed out major recent advances in glaucoma surgery that are improving outcomes, such as a shift from full-thickness to guarded filtering procedures, and incremental advances, such as scleral flap construction and closure.

Although complications are common with trabeculectomy, very few have the potential to cause severe visual loss. People also tend to underestimate the risks of medical therapy and overestimate adherence to it. He equated the doctor-patient relationship to the old joke: “They pretend to pay us; we pretend to work. Well, in glaucoma, we pretend to treat them; they pretend to take our drops.”

And not to disappoint, Dr. Heuer closed with a medley of glaucoma-themed cover songs, the last of which was “Yesterday,” by the Beatles. Here are the first two verses:

“Yesterday, loss of vision seemed so far away
Then I underwent trabeculecto(may)
Oh, I long for yesterday.

Suddenly, my vision’s half of what it used to be
There’s a shadow hanging over me
Oh, vision loss came suddenly.”

Anti-VEGF reimbursement rates affect patient choice of drugsHow does a Medicare plan’s significant cut in the reimbursement rate for Lucentis affect which anti-VEGF drug patients choose? Mitchell S. Fineman, MD, presented data during Friday’s Retina Subspecialty Day on how such a change affected use of Lucentis (ranibizumab) and Avastin (bevacizumab) at his retina subspecialty practice in New Jersey and Pennsylvania. The results are not surprising.

In 2011, the Medicare Advantage Plan A changed its reimbursement rate for Lucentis from 100 percent to 80 percent. Dr. Fineman explained that patients now have to pay approximately $400 for a single Lucentis injection, whereas they previously had a small copay. “They are angry,” he said.

Data from his practice show the following changes in treatment of wet AMD between the last quarter of 2010 and the first quarter of 2011:

Lucentis use dropped from 94 percent of anti-VEGF injections to 33 percent among Medicare Advantage A patients.

Avastin use jumped from 6 percent to 67 percent among Medicare Advantage A patients.

Ocular Response Analyzer measurements may not be useful in diagnosing keratoconusDuring Refractive Surgery Subspecialty Day, Bruno M. Fontes, MD, today presented the paper that won him the Troutman Prize, which recognizes the scientific merit of an article published by a young author in the Journal of Refractive Surgery.

Dr. Fontes and colleagues used the Ocular Response Analyzer to measure the corneal hysteresis (CH) and corneal resistance factor (CRF) in 19 patients with keratoconus and a central corneal thickness of at least 520 ?m and compared the results with healthy matched controls.

They found that CH and CRF were statistically lower in the keratoconus group than in controls. However, due to the large overlap in values between groups, both CH and CRF had low sensitivity and specificity for discriminating abnormal corneas.

“This is the exact type of work we need,” said J. Bradley Randleman, MD, editor-in-chief of the Journal of Refractive Surgery. “It’s important to scientifically vet technology. It’s tempting to use CH and CRF, but those two numbers are not good enough. It’s not to say the technology isn’t good, but it requires a deeper look into exactly where the information may lie.” —Susanne Medeiros

The Quotable Ophthalmologist“Don’t be a tool for The Man. Let’s be doctors for our patients,” said Thomas S. Harbin, MD, at the Glaucoma Subspecialty Day in his presentation, “The Ethics of Glaucoma Care.”

“To say that this study has generated some discussion among ophthalmologists, pediatricians and neonatologists would be an understatement,” said Kanwal K. Nischal, MBBS, program co-director of Pediatric Ophthalmology Subspecialty Day, referring to the BEAT-ROP study.

“The only patient whose adherence you know is the patient who tells you they’re not taking their medicine,” said Dale K. Heuer, MD, during the AGS Subspecialty Day Lecture.

“These people have lost their sight, but their vision will change the future,” said Egyptian ophthalmologist Sherif M. Sheta, MD, in his “Trauma During Revolution” presentation during the Retina Subspecialty Day.

Opening Session features Academy’s plans to shape the future in turbulent timesThe 2011 Annual Meeting opened today with Academy leaders making a strong case that investing now in the creation of a clinical data registry will better equip ophthalmology for the turbulent times ahead.

“It’s all about the data,” said David W. Parke II, MD, the Academy’s CEO and executive vice president. “Having it and using it efficiently and effectively.” It’s one thing to claim that our complication rates are low, Dr. Parke explained, but it’s quite another to prove it with data showing better patient outcomes.

Dr. Parke said the Academy plans to create a clinical data registry for ophthalmology, a profession-wide database of specifically chosen clinical data points from individual patient encounters. It’s important that the Academy does this for the profession. If we don’t, an outside entity will. “We need to define ourselves, rather than letting others define us,” Dr. Parke said.

A robust clinical data registry will become an important tool both to improve patient care and to “advocate for ophthalmology in the turbulent times ahead,” Dr. Parke said.

Can it be done? The Society of Thoracic Surgeons (STS) has already done it, to the great advantage of both their profession and their patients.

The STS National Database was established in 1989 as an initiative for quality improvement and patient safety among cardiothoracic surgeons. Within just three months of its creation, physician adherence to clinical guidelines had increased.

A panel discussion moderated by Michael X. Repka, MD, considered the issue further and took questions from the audience. The panel consisted of Drs. Anne L. Coleman, Cynthia Mattox, William Rich III and Alfred Sommer. Here are some highlights:

Will data-driven guidelines stifle innovation? “It’s always a concern,” said Dr. Coleman. “The guidelines are there to support you. Integrate them with your clinical judgment and intuition. They are a tool, not a checklist.” Dr. Rich said he believes that guidelines will stimulate innovation because better data will lead to more innovation.

Won’t registries just lead to more “secret police” monitoring our activity? “They’re already looking,” said Dr. Sommer. “We want to make sure they see the right thing.” Dr. Rich added that “it’s not just the police, it’s the public,” referring to the explosion of websites rating doctors and their performance. “Patients are paying more, so they want more.”

Won’t it favor optometrists, since they can provide service at a lower cost? “That’s exactly why we have to do this,” said Dr. Sommer. “To show the value of ophthalmology, to show that optometrists provide lower quality at lower costs.

This point was made in an inspiring new Academy-created video shown before the session began. The intention is to demonstrate to the public how ophthalmology delivers quality eye care.

Will the ophthalmology community accept it? “We already have credibility with our members,” Dr. Rich said. “If the guidelines are created by us, they will. We have a 25-year record of building trust with our members.”

Will it shorten the time it takes for the community to adopt scientific innovation? Dr. Sommer answered with a quote from Max Planck. “An important scientific innovation rarely makes its way by gradually winning over and converting its opponents. What does happen is that the opponents gradually die out.” Despite the laugh line, Dr. Sommer does believe the lag time is dropping dramatically, pointing to the rapid adoption of Anti-VEGF treatments. —Susanne Medeiros

Contacts: not the same old optionsOptical properties of the newest contact lenses are based on the same principles as those used in premium IOLs. As a result, a whole new world has opened up for patients, said Deborah S. Jacobs, MD, speaking during today’s “Contact Lenses in the 21st Century” Symposium. Here’s a brief overview of the new options:

Toric contacts. Used for astigmatism, these lenses are available in plus and minus spherical powers, and options for daily disposable wear are increasing. RGP lenses can be made bitoric.

Aspheric contacts. These can reduce higher-order aberrations, whether they are innate or are associated with contacts (e.g., related to decentration or power). They improve depth of field and are available as soft or RGP lenses.

Bifocal contacts. Myriad design options are available. For instance, the add can be segmented or concentric, and segment size can be varied. As with IOLs, aspheric and diffractive optics are available. Center distance and center near vision are options, and the near can be true near or midrange.

Multifocal contacts. Dr. Jacobs said that “infinite combinations” are possible, given that you can have a different add or distance correction for each eye—and that you can employ paired designs from different companies.

Wavefront contacts. This is “the last frontier,” Dr. Jacobs said, and it offers the potential of true custom design. Wavefront contact lenses are in the development stage.

Clinical pearls. Dr. Jacobs offered the following advice:

Employ monovision. Remember that modified and part-time monovision are options.

Encourage experimentation. Use daily disposables and trial lenses, and encourage patients to “play” with the lenses until they find what is right for them.

Be aware of the pros and cons. The new contact lenses allow for optimal vision, they’re a practice builder and they’re much easier to employ than IOL exchange. On the other hand, they require more chair time and a skilled fitter/trainer. In addition, you need to keep abreast of new developments and may need to have a substantial inventory on hand. —Jean Shaw

Fifteen years after the Endophthalmitis Vitrectomy Study: Where are we now?On Saturday, a group of speakers discussed what has changed in the management of postoperative endophthalmitis since publication of the highly influential Endophthalmitis Vitrectomy Study (EVS) in 1995. That randomized trial, which included 420 patients with clinical evidence of endophthalmitis within six weeks after cataract surgery or secondary IOL implantation, concluded that systemic antibiotics were unnecessary to treat postoperative endophthalmitis and that an initial vitreous tap/biopsy was generally sufficient treatment if the presenting vision was hand motions or better. It also concluded that immediate vitrectomy was useful only for cases in which the presenting vision was light perception only. Discussion points included:

Since the EVS, there have been only a few small studies examining the management of postoperative endophthalmitis, and their results have been conflicting. This may be due in part to the low rate of endophthalmitis in the United States.

Developments since 1995, such as the use of intravitreal corticosteroids, subconjunctival antibiotics, and small-gauge PPV, have introduced new questions.

The Great Debate tackles treatment of wet AMDToday’s Great Debate featured some competitive, yet friendly, sparring. Five controversial topics were each debated by two ophthalmologists. Donald J. D’Amico, MD, served as moderator, explaining that he had asked the debaters, in some cases, to take on viewpoints they had not previously held.The topic of one of these debates was the statement: “Given the results of the CATT trial and VIEW trials (and assuming approval of VEGF-Trap Eye), the primary treatment for wet AMD should be Avastin, not Lucentis or VEGF-Trap Eye.”

Charles C. Barr, MD, argued in favor of the statement. He noted that the main difference between Avastin and Lucentis is cost. The results of the Comparison of Age-Related Macular Degeneration Treatments Trial (CATT) showed that, the two drugs had equivalent effects on visual acuity at all time points throughout the first year of follow-up. And there were no differences in terms of intraocular adverse events or in the incidence of heart attack and stroke. “

Even though Lucentis was designed for AMD, it turns out that Avastin is equally effective,” he said, noting that neither drug completely dried the retina. He said he’d like to try VEGF-Trap Eye before professing any opinions about it, but he proclaimed that Avastin was already the drug of choice due to efficacy and lower cost.

David M. Brown, MD, dramatically opened the con argument by zeroing in on three recent incidents around the country in which a total of 21 patients lost some or all vision in the affected eye after due to a bad batch of compounded Avastin.“

The FDA is there to protect us from adulterated drugs,” Dr Brown said, “to assure you and your patients that there’s no chance of endotoxins or bacteria in the drugs you use.

Noting that Lucentis and Avastin are packaged under very different conditions, he said, “A compounding pharmacy cannot replace a robot in a sterile room.”

“This scare tactic kind of stuff is really off the mark,” Dr. Barr began his rebuttal, noting that ophthalmologists use other drugs that are not FDA approved. He said that in the CATT study, there was no difference in infection rates between patients treated with Lucentis or Avastin. “It’s in our patients’ best interest to use the cheaper drug,” he said.

Dr. Brown had the last word, making an analogy between drinking cheap liquor and using drugs formulated at a compounding pharmacy. “It’s going to be efficacious. It will get you drunk. But some patients will go blind. You’re trading patient safety for dollars and it’s unacceptable.” Dr. Brown’s argument appeared to be the most persuasive. Before the debate, 65 percent of audience members supported the statement, but only 60 percent did so afterward. —Lori Roniger

Dr. Barr is a consultant to EyeTech. Dr. Brown is a consultant for Alcon, Alimera, Allergan, Bayer Pharmaceuticals, Carl Zeiss Meditec, Genentech, Heidelberg Engineering, Molecular Partners, Novartis, Pfizer and Regeneron. He also receives grant support from Genentech and Novartis and lecture fees from Heidelberg Engineering and Regeneron. Dr. D’Amico is a consultant to and equity owner in Ophthotech and Optimedica.

Video interviewsAcademy staff are conducting short video interviews with meeting presenters, attendees and other key figures to see what they’ve heard and learned so far.

2011 Laureate Award honoree Alfred Sommer, MD, MPH, describes what he looks forward to each year at the Annual Meeting and the one session he just won’t miss.

Museum of Vision Director Jenny Benjamin highlights the camera used to take the first fluoroscein angiogram—one of the fascinating pieces of ophthalmic history on display at the museum’s exhibit in Orlando.

Chairman of the Academy’s Medical Information Technology Committee Michael F. Chiang, MD, talks about the Academy’s development of guidelines for EHR systems and how ophthalmology practices can use them to compare systems. (The Academy has published a checklist of the 23 recommended features, along with responses from 15 vendors. Pick it up in Lobby A/B or Lobby C or download it from EyeNet’s website.)

Check the Annual Meeting group in the Online Community for additional videos from Orlando (members only).

The Quotable Ophthalmologist“I worry about the naive user, who perhaps wears these on a dare, then all hell breaks loose,” said Thomas L. Steinemann, MD, during his presentation, “Dangers of Decorative Contact Lenses” at today’s “Contact Lenses in the 21st Century” Symposium.

Throughout the day, there will be discussions devoted to leadership, EHRs and “Meet the Producers,” where you can ask questions about some of this year’s Scientific Videos. See the full schedule online.

Femtosecond-assisted cataract surgery: How good is it?Since 2008, 150 surgeons from 16 countries have performed 6,000 femtosecond-assisted laser cataract surgeries showing that the laser brings unprecedented precision and reproducibility to the process of creating a capsular opening. But, really, how much better is it than manual surgery?

Robert J. Cionni, MD, conducted a prospective study to find out. He compared 50 eyes undergoing cataract surgery, in which he performed either a femtosecond-created 5-mm capsulotomy (LenSx laser) or a manual continuous curvilinear capsulorrhexis with an attempted diameter of 5 mm. About 70 percent of eyes in the laser group were within 0.25 D compared with 54 percent in the manual group. The increased accuracy led to better refractive results: 59 percent could see 20/25 or better in the laser group compared with 52 percent in the manual group.

Where the femtosecond laser’s accuracy and stability really count is with premium IOLs. Dr. Cionni said that 100 percent of his ReStor patients could see 20/25 or better when he performed surgery with the femtosecond laser. “We are truly moving into the realm of cataract/refractive surgery,” he said. —Susanne Medeiros

Dr. Cionni is a consultant and lecturer for Alcon and has a patent and/or receives royalties from Morcher.

Genetic testing for AMDIs genetic testing the next big development in neovascular AMD? Ivana K. Kim, MD, in her presentation at Saturday’s Retina Subspecialty Day, offered the following points:

It’s already here. Several genetic tests are widely available; some are sold directly to patients. (Tests include Macula Risk, RetnaGene, deCODE genetics, 23 and me, and ARUP Laboratories.) The tests will likely become a component of current and future clinical studies.

But the clinical utility is unknown. Consistent associations have not been established between genotype and response to anti-VEGF treatment. However, there is some evidence to suggest a decreased benefit from AREDS supplements in patients with the CFH Y402H risk allele.

Social issues are unclear. Legal, ethical and social implications have not been adequately addressed. The experience with diseases such as breast cancer and Alzheimer’s is instructive. —Jean Shaw

Dr. Kim receives grant support from Genentech and is a consultant for Regeneron.

The IOL is a one-piece, anterior chamber iris-fixated lens, which is attached to the iris with two clips, offering an effective solution for eyes with insufficient capsular support.

It has become the lens of choice for aphakia in the Netherlands, where it was introduced in 1978. It is not yet FDA approved in the United States.

The surgical technique involves removing the crystalline lens and capsule, constricting the pupil with carbacholine or acetylcholine, filling the anterior chamber with viscoelastic, and then inserting the Artisan through a 5-mm incision and attaching the claws to the iris by enclavation of peripheral iris tissue. A peripheral iridectomy is necessary.

Advantages: Because the lens doesn’t have to be placed in the capsular bag, it is easily removed and replaced, a major advantage for children’s eyes. There is no need for angle support, pupil fixation or transscleral sutures.

Concerns: Although small case studies with follow-up as long as 10 years show no significant differences compared with control eyes, there is some concern about a long-term negative effect on corneal endothelial cell density. —Annie Stuart

Ocular surface disease—replacement vs. regenerationSaturday’s Cornea Subspecialty Day opened with a panel discussion, moderated by Anthony J. Aldave, MD, reviewing two alternate approaches to corneal transplantation: 1) replacing diseased tissue with keratoprostheses or 2) regenerating the tissue, either by cultivating cell sheets to be transplanted into the eye or by using a biosynthetic cornea that integrates with the eye and stimulates regeneration.

The Boston Keratoprosthesis in the management of limbal stem cell failure. Presenter: James Chodosh, MD, MPH.

The Boston KPro is a collar-button type of artificial cornea—the most common treatment for patients with severe corneal opacity.

The device is inserted into a corneal graft, which is sutured into the cornea. If the patient is phakic, the lens is removed. A soft contact lens is applied to the surface.

It is an alternative for patients with corneal allograft failure and pediatric patients with poor prognosis for conventional allograft.

Advantages: The procedure shows long-term stability and has undergone improvements since its inception in the 1960s.

For more on the KPro, see the EyeWikior EyeNet’s “The Nuts and Bolts of Keratoprosthesis,” PartsOneand Two(members only).

Corneal epithelial reconstruction with cell sheets is a new technique that involves removing oral mucosa from the lip and cheek, cultivating and expanding the tissues in the lab and transplanting them onto the ocular surface.

This technique provides an alternative to allograft transplantation.

Initial results are good, including a Stevens-Johnson syndrome suspect with 20/30 vision three years postoperatively.

Advantages: This approach provides an option for bilateral disease, doesn’t involve the healthy eye and requires no immunosuppression.

This is a novel procedure, involving a feeder-free explant culture system containing human autologous serum and human recombinant growth factors.

It provides an alternative to direct limbal transplantation.

Advantages: This procedure requires smaller amounts of donor tissue, which reduces the risk of inducing iatrogenic limbal stem cell deficiency (LSCD) in the donor eye, and is safe for total or partial LSCD. Significant percentages show long-term improvement in the ocular surface and improved vision.

Dr. Chodosh is a consultant for Alcon, Allergan and the National Eye Institute, and also receives grant support from the NEI. Dr. Fagerholm reports no related financial disclosures. Dr. Gomes is a consultant for Allergan and Natura, receives lecture fees from Alcon and Allergan and receives grant support from Natura. Drs. Liu, Nishida and Sangwan report no related financial disclosures.

Conquering complicated cataracts, learning from patients
The physician who brought us 10 years of "Spotlight on Cataract" today featured his most challenging case ever, as he delivered the Charles D. Kelman Lecture.

It was 1998, and David F. Chang, MD, was referred a tough case: a 61-year-old author with severe scleritis and uveitis. She was blind in one eye, had secondary glaucoma (bleb failure) in the good eye, a thin cornea and a rock-hard nucleus.

The scariest part, he said, is that he didn’t really have a backup plan. The zonules were loose, and in the video, you can see the lens bobbing away from the phaco tip. But in the years since he performed that surgery, many innovators have come up with devices and techniques to better deal with weak zonules.

Dr. Chang showed a string of videos demonstrating various devices and approaches that he has since learned in order to manage a range of zonulopathy. You can find Dr. Chang’s full video series on the Academy’s Ophthalmic News & Education (ONE) Network. Called the Master Class in Cataract Surgery, it includes 32 videos showing how he manages the broad spectrum of zonulopathy associated with pseudoexfoliation, trauma and other causes.

Ultimately, Dr. Chang’s patient had a good outcome. Nine years after the surgery, he told her she was his most “terrifying” case. But one month after their visit, she fell, ruptured her globe, lost vitreous and half her iris. Vision in her one good eye was now counting fingers. One year later, she committed suicide.

He said this case taught him about the “tremendous risk and burden and stress we take on when we operate on the patient’s only good eye.” Dr. Chang then provided a long list of innovators and innovations that he has learned from. At the top of the list was Charles Kelman, who came up with the idea of performing cataract surgery through a tiny incision.

As we ponder whether the femtosecond laser is the future of cataract surgery, he urged the audience to “pause and reflect and marvel at the fact that cataract surgery is the most common operation in all of medicine. And we’re still doing it with the basic ultrasound technology Charles Kelman developed 25 years ago.”—Susanne Medeiros

Dr. Chang is a consultant to AMO, Alcon, Clarity, Hoya, Ista, LensAR and Transcend Medical; he receives lecture fees from Allergan, Bausch & Lomb and Carl Zeiss Meditec; he has an equity interest in Calhoun Vision, Clarity, ICON bioscience, LensAR, Revital Vision and Transcend Medical; he has a patents/royalty interest in Eyemaginations and Slack; and he receives grant support from Glaukos.

When vision improvement causes big changes in behaviorIn a study titled “Improvements in Behavior Following Refractive Surgery in Neurodevelopmentally Delayed Children” presented at today’s “Late Breakers” Symposium, Evelyn A. Paysse, MD, showed how improving high refractive error with pediatric PRK can dramatically improve behavior in neurodevelopmentally delayed children who are not compliant with standard therapy.

Over the last 15 years, about 600 cases of pediatric excimer refractive surgery have been published in the literature. Forty cases of phakic IOLs and 20 refractive lens exchange cases have also been studied. All showed improvements in uncorrected and best-corrected visual acuity and refractive error with few complications.

“Past studies had examined this previously, but they relied on parental questionnaires to evaluate functioning and socialization,” said Dr. Paysse. In this study, 14 children were evaluated with standardized tests, including a developmental quotient (DQ; developmental age in months divided by biological age in months x 100). A developmental psychologist measured the DQ both preoperatively and postoperatively.

Improvements in DQ are rare in neurodevelopmentally delayed children, said Dr. Paysse. “But in this study, the children showed statistically significant improvements in DQ subdomains of socialization and communication six months after treatment.” This included 85 percent experiencing an improvement in communication.

Children who once were living in a world of visual blur and isolation, averse to touch and very combative became much more outgoing and playful, said Dr. Paysse. The words of one parent may express it best: “Thank you for trying to help our child when no one else thought it was worth it because he had so many other disabilities that they thought it wasn’t important for him to see very much.”—Annie Stuart

International Workshop on MGD
Over a two-year period, the more than 50 experts participating in the International Workshop on Meibomian Gland Dysfunction created a consensus definition of meibomian gland dysfunction (MGD). They also developed a clinical classification system, description of the cause and potential effects of the pathology, diagnostic techniques for grading the disease, and an algorithm for therapy based on clinical staging. Gary N. Foulks, MD, presented some highlights during Sunday afternoon’s “Late Breakers” Symposium.

Rather than being considered synonymous with posterior blepharitis, MGD is now considered one of its causes. MGD is defined as a chronic diffuse abnormality commonly characterized by terminal duct obstruction and/or qualitative or quantitative changes in glandular secretion. These abnormalities may be the leading contributor to dry eye disease.

Expressing the gland and evaluating secretions is considered a critical step in diagnosis of any suspect. A new staging system from I to V is then used to develop clinical management, ranging from dietary changes and good hygiene to therapies such as tetracycline and anti-inflammatories.

Guidelines for future research can be found in the full report available in the March 2011 Investigative Ophthalmology & Visual Science or at the Tear Film and Ocular Surface Society website.

—Annie Stuart

Dr. Foulks a consultant for Alcon, Bausch & Lomb Surgical, Eleven Biotherapeutics, InSite Vision, Ista, Merck, Otsuka, Pfizer, Scynexis and TearLab/Ocusense; he is also a speaker for Alcon and TearLab/Ocusense.

Time to invest in femtosecond technology?
During Sunday’s “Spotlight on Femtosecond-Assisted Surgery,” cataract surgeons discussed whether it’s better to invest in femtosecond-assisted cataract surgery technology now or later. Robert J. Cionni, MD, said that the time has already come for practices to jump into using this technology, while David F. Chang, MD, was more circumspect. However, they agreed that any practice considering using femtosecond lasers for cataract surgery should first run some numbers and develop a financial strategy.

“I firmly believe that femtosecond cataract surgery is the future of cataract surgery,” said Dr. Cionni, whose practice has performed 600 laser cataract surgeries, most done by him. “When should you pull the trigger? I’m telling you that it is ready. The question is whether you can afford it.”

He said that practices should consider some basic questions: Is it too early? Is it a safe and reliable procedure? Will it provide a benefit to the practice’s patients? Can your facility afford it?

In order to answer the last question, he said that a practice should develop a business plan. He noted that the technology continues to change, with systems undergoing multiple software upgrades.

“The challenge is that it is very expensive for a procedure we are already doing very efficiently,” Dr. Chang said.

He added that it is hard to know what the benefits of the technology are, since there is a lack of data, and he questioned whether money might be better spent on other technologies. Meanwhile, he is optimistic that femtosecond laser technology will get better and cheaper.

He, too, said that practices need to consider some financial and clinical questions before investing in the technology: How much of a clinical benefit will it provide? Who will pay for it? Will physician compensation be enough to offset the increase in workflow?—Lori Roniger

Dr. Cionni is a consultant to and receives lecture fees from Alcon, and has a patents/royalty interest in Morcher. Dr. Chang’s financial interests are listed above.

Femtosecond Scientific Papers
Sunday’s Scientific Papers included a session devoted to the femtosecond laser. Summaries of the presentations follow.

Femtosecond Laser Titratable Astigmatic Incisions in Cataract Surgery. Presenter:Stephen G. Slade, MD. Cataract surgery was combined with adjustable femtosecond laser astigmatic incisions to treat preexisting astigmatism in 30 eyes. To achieve the precise, desired effect, incisions were opened manually at the slit lamp after surgery. Results of this first case series showed a 70 percent reduction in preexisting cylinder and no complications.

Optical Impact and Clinical Significance of Corneal Fold Formation in Laser Cataract Surgery—rated Best Paper. Presenter: Jonathan H. Talamo, MD. The study compared capsulotomy using a curved contact lens surface in 54 eyes to a noncontact liquid interface in 39 eyes. No corneal folds (CF) were identified in the liquid interface cohort, while corneal folds were identified in 70 percent of the curved contact interface cohort, with a subset experiencing incomplete capsulotomy incisions beneath the CF.

Facilitation of Nuclear Cataract Extraction Using Femtosecond Laser Pretreatment. Presenter: William W. Culbertson, MD. Thirty-nine eyes received laser capsulotomy and lens fragmentation. When compared with the control group of 29 eyes, cumulative dissipated energy in laser cases was 47 percent lower in grade 1 to 3 cataracts and 45 percent lower in grade 4. Using the laser to segment the lens resulted in 45 percent fewer active steps (i.e., phaco tip movement with power on).

Comparison of Diameter, Circularity and Centration of Capsulotomy Created by Femtosecond Laser and Capsulorrhexis Created by Manual Technique. Presenter: Juan F. Batlle, MD. This study compared size, shape and centration of femtosecond laser capsulotomies in 39 eyes with 29 eyes receiving manual capsulorrhexis. Femtosecond laser disks had a deviation from intended diameter of 29 ± 26 µm versus 339 ± 248 µm for manual capsulorrhexis. The circularity index (1 is a perfect circle) was 0.936 for laser disks and 0.774 for manual. Centration for femtosecond laser capsulotomy was within 77 ± 47 µm of intended results.

Effective Lens Position Following Laser Anterior Capsulotomy. Presenter: Warren E. Hill, MD. This study compared effective lens position in patients undergoing laser capsulotomy (LC)—with or without laser phacofragmentation—to those undergoing manual capsulorrhexis (MC) with laser phacofragmentation. Eighty-one percent of subjects in the LC group and 75 percent in the MC group were within 0.50 D of intended spherical equivalent, with LC resulting in significantly less mean refractive error and MC producing more myopic error.

Endothelial Changes After Laser Phacofragmentation. Presenter: Mark Packer, MD. Endothelial cell density was measured at baseline and at three months postoperatively to compare the effect of laser phacofragmentation in 225 eyes to conventional phaco in 63 eyes. At three months, endothelial cell loss was negligible in both groups. At six months, mean changes in cell loss were –1.5 percent in the laser group and –4.8 in the conventional phaco group.

Comparison of Conventional and Femtosecond Laser–Assisted Phacoemulsification on Dense Nuclear Cataracts. Presenter: Zoltan Z. Nagy, MD. This study compared the efficiency of conventional and laser-assisted phacoemulsification in dense nuclear cataracts in 40 eyes by assessing the numbers of phaco manipulations and cumulative dissipated energy (CDE). Compared with the control group, use of the laser for lens fragmentation reduced mean CDE by 32 percent in dense cataracts and by 42 percent in all grades of cataract. Corneal edema and endothelial cell loss in the laser group were also reduced postoperatively.

Refractive Index Shaping of 3-D Structures Inside Hydrophobic IOL Material Using Femtosecond Laser Pulses. Presenter: Josef Bille. This presentation reported on the development of a noninvasive method for fine-tuning refractive error in situ. The technology uses high-repetition, rate-focused femtosecond pulses for refractive index shaping, which creates 3-D structures of different refractive indices inside the hydrophobic acrylic IOL. Early results suggest the ability to customize power adjustment, including in multifocal lenses, with focused femtosecond laser pulses without changing the surface of the lens.

—Annie Stuart

Financial disclosuresDr. Batlle is a consultant for Bausch & Lomb, Innovia, Lenstec, Opko, Optimedica and Staar Surgical. Dr. Bille is a consultant for and has a patents/royalty interest in Aaren Scientific. Dr. Culbertson is a consultant for AMO, Hoya Surgical Optics and Optimedica; he has an equity interest and a patents/royalty interest in Optimedica; and he receives lecture fees from AMO, Alcon, Carl Zeiss Meditec and Hoya. Dr. Hill is a consultant for Alcon, Bausch & Lomb, Carl Zeiss Meditec, Elenza, Haag-Streit, LensAR, Oculus and Santen; he also receives lecture fees from Alcon and Carl Zeiss Meditec. Dr. Nagy is a consultant for LenSx Lasers. Dr. Packer is a consultant for AMO, Advanced Vision Science, Bausch & Lomb, Carl Zeiss Meditec, Celgene, Ista, LensAR, Rayner Intraocular Lenses, Transcend Medical, TrueVision Systems and WaveTec Vision Systems; he also has an equity interest in Corinthian Trading, LensAR, Surgiview, Transcend Medical, TrueVision Systems and WaveTec Vision Systems; and he receives lecture fees from General Electric and Haag Streit. Dr. Slade is a consultant for Alcon, AMO, ForeSight Labs, LenSx, RVO and Technolas; he has an equity interest in Alcon and LenSx; and he receives lecture fees from Alcon and AMO. Dr. Talamo is a consultant for Allergan, Ikona, Nexis Vision and Optimedica; he has an equity interest in Optimedica; he has a patents/royalty interest in Ikona; and he receives lecture fees from Alcon, Allergan and Bausch & Lomb. Dr. Uy is a consultant for and receives lecture fees from Alcon; and he receives grant support from LensAR.

Video interviewsAcademy staff are conducting short video interviews with meeting presenters, attendees and other key figures to see what they’ve heard and learned so far.

Edward J. Holland, MD, discusses new lamellar procedures in keratoplasty and other notable topics that came up during the Cornea/External Disease session he moderated in the Academy Café.

Robert J. Cionni, MD, talks about why he thinks the time is right to invest in a femtosecond laser for cataract surgery.

Michael Chiang, MD, discusses a scientific poster on a randomized trial comparing postoperative complications between aphakic and pseudophakic pediatric eyes under two years of age.

Watch highlights from Sunday’s opening session, where Academy leaders spoke about the Academy’s plans to invest in the creation of a clinical data registry. “We ophthalmologists have the professional responsibility for the eye care of all humanity—taken one person at a time. We have the intellect, we have the training, and we have the experience. What we don’t have, and what we desperately need, is the evidence of the impact of our work,” says David W. Parke II, MD, the Academy’s CEO and executive vice president.

Check the Annual Meeting group in the Online Community for additional videos from Orlando (members only).